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Brock, Cheryl A Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: -__.. h11�" ---------....._.---------•-•-----._..._..... .._-. ..------- RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: . _-_ 1 1104I 3-IG NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: -- -- fkY._..-.. --hlcG NAME: t i C .._ -.._---_-VROC� _- ----------- _CASE # 7(7 - TYPE OF CONTAINER: 1 i.d (p, ------- ' � '�-t`� .ci''_...��_� �p„►��oOl� 1 /gyp i•l ZV/pir PLACE OF DEATH: ESTIMATED WEIGHT OF REMAINS & CONTAINER_ __ Ihr//131.>__&,..5c4,14_ PLACED IN HOLD: 3:3p en PLACED IN REFRIGERATION: DATE OF CREMATION: _/f-//-Zoe__ ._....-------- --------------------- TIME STARTED: JAE _TIME COMPLETED: g _ - PLACED IN RETORT: 14 f - -- -MOVED: 4. ! _ RETORT# IN WHICH REMAINS WERE CREMATED: _&jer rI k DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL RE RETAINED IN THE PERMANENT FILE OF THE CREMATORY. lab YOt.(Sint EWYo rc Division of DIVISION Mt'f State STATE OF dtV1514N OF CEMETERIES PORTUNITY. Cemeteries i shnCcoririft rfe rin.a '?'�1+ldshnrnn AYCIYJt A 3err!'.NY'77 1-3 1 •ela.^.e5one:Ma)474622G emagit,<riy.cov - Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation, Num Der: Crem tcry Name Pine View Crematory Addrees ouakter Rd.,Oueensbury. ts'•'126C4 Phone. 18-r'45,4.377 CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS_ Cremation is carried OA by p1130-1TV the re-rains cat[tic deceased und the rnc' incr holding tho remains into a cremat in chamber whore they are subjected to intense hest and lame The heat and flame will incinerate and consume everything except bone and metal, which are all that will be left after cremation. Fcc era ing c emation,the crematory will take national<e eftroi to remove sill of the reme ns and.other rnatenal from tie cremation 'thamber,but Some minim* dust and rerrioi a wits lii'cety be let aehin;! The crematory seoarate incidental and foreign material from the remains and the ''Kider zal and!nitign material will be cape iud of as required by law. The;•txernated mains be mectianemllyr 1 ou li erieod into small pieces we placed into a igra:ed container or uir` Cremated remains generally are pulverized until no Lsingte fragmtrtt is recognizable as skeletal tissue. OPENING OF THE CONTAINER The cremator/may only open re Oonta,:-e'hcloi.y the ur-rremutec human rerrlairs ^limited car;ums?anccs,sum as to confirm the Oentity of the deceased or to unsure that no rrateriai is enclosec wh t right injure employees or damage.he Crematory property. If human remains are delivered in a container which is not suitable for eromation such as ceremonial or rental casket,the crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of e container or the transfer cr renew'of rema ns .ti,F be cenc.:oiod be=ore a witr•tss and w. :k`d done:n privacy, with dignity and respect IDENTIFICATION OF DECEASED Name or Doceased:Cheryl �rrs;X+c t,P�:i i:v Manta'Statue: Last Known ?address: er'"tllrrut Ave.: I arctimont,ta'�1 aS3e Place c,'Ocatn:88 h+alrispering Woods Way. Long I al .N'" 121147 sex: ©ht I F Age 75 _ LOR 10/25/t 94 s nub of Oeatn g�1 v L'21 sb natal"lvelght. 15° 3escripl can a{cametrconte her in which rema ris ekii:be,delivered. MacDonald Container; basic cardboard cremation container; no interior PERSON IN CONTR%OF O=SPi: 11'1ON (Perar]Ir'r(C)ill Scfitroi chf',isposition "nri 7i �.~r'1�C{rfr�� L?.""owiP•gi l em irrie are the demo-a1ed agent of:he.creased.'je tir.od in a w. Cr•1.i'te in_e1n;rnt rrt exec.:ted pursuant to Public Health Law lion 4231. -•L},Cr,- t,.f IAive have no kr.treict.tidge that t:^�iiccaas�ex,s;�.,:@d a v►riten +r7g,:rure.t purgvu.tit to Public Health Law:lion 4201 or a will containing direr ions for the disp> itor cf r s Or tot-romans and 1r o'e are the t:iecscriiisi havrg priorty under Public Health I owl Socbovi 4201 and have the nget!c auttio xe:xcrrlatoh of the Vnairs of the deceased &fylOur relationship to the deceased is as follows Cheryl A. Brock Na..41..lrf vsc,it )OS-18t; ff itev.GAO:. Page' or Authorization for Cremation and Disposition (trrrhar the fo.k wrri j) IN We understand that if the remains are not claimed within 120 days of crematon. Alm View Crematory a ",rvGTcm:,ry may diSOusc of the remains in an irretrievable manner.such as by Scattering CREMATION CONTAINER/URN rnIPAl ONE of the following) An urn 10 be used as a e retainer for the cremated remains has been corerieSed frcm and aS described as renews: tvWe understand that i'the urn is Ion small to fold the entire cremated remains, an additional rigid container may be used for delivery. -4R- An isrm,is not yet purchased. Wife understand that if no urn is purchased Of Otherwise orovide Pine View Crematory nt�*r or cr: will p2ace The cremated remains a rigid temporary Container for deiruery. This Authorization Form was croinded by Patricia Miller was executed at HCRie 6357 NYS Ate 30, Indian Lake NY 12842 — -'—'I aess; and is gonad by the furee,director as witness to its execution LbVe have received a oompretcd oc'of this Authorization Form The person(s)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,atteat(s) to the accuracy and completeness of the information contained in this Authorization Form and authorize{aj the foregoing. Signed this day of August 20 21 William G.Brock t. �..tavef n• 'i!O ld,:rOf ... •'yj�3L'.' 1 n Walnut Are., Larchmcrt, NY 10688 :y'p'r'-'?MAttsi Nam ti"r14\r ji�Irlr00t _.. l low!nr Prirtteml klamt Nr...vR1.tT lI WITNESS: • Para Millet meow Toed'.�. a!t,ewl 1246S A- arOCK 'maw nr oecews e0 DOS-1898-f(Hey 04.'20) Page 3 of 3 Authorization for Cremation and Disposition tm$Ort from Me.mot below) Number Descripaion: 1. A person designated in writing pursuart to Public Health Law Section 4201 i3): 2. 1 he strviving spouse; 2a. The surviving dcxnestic pa-lner 3_ Any surviving child eighteen years o►age or older, 4. A Surviving parent; 5 A surviving sibling eighteen years of ago or older 6_ A lawfully appointed guardian: 7- Any person(s)eighteen years of age or older entitled to share in the estate and who isiare closest in relabo nstiip to the deceased: 8. A duly appointed fiduciary of the estate. 9. A dose friend or relative who has execs ed a written statement pursuant to Public Health Law Section 4201(7}; 10. A chief fiscal officer of a courrty or a public administrator appointed pursuant to the S,,ruyate'S Court Procedure Act 10a. Any Other person who is acting on behalf at the deceased and who has executed a written statement pursuant to Put&F c Health Law Section 470117. ()Th JAL THAI r-of the fd,lowrri5c1.; �. .Ma hereby affirm that the body of the deceased aces root contain a oattery. clattery puck, power cell. radian=true in lent or rad►oaCtive device and that any such materials were removed prior to the execution of this Authorization Form_ Failure to remove theme items prior to cremation may result in harm to the crematory and crematory personnel. iNVe affirm that irstructions have been given to Patricia Miller "'We, Nranni regarding the removal of any personal property or other thin of value which any person signing below or any Family member of the deceased wishes to preserve. Pine View Crematory 17FV.1uy is not responsible for the removal of personal items from the container or Iran the remacns of the deceased. Personal items left In the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. I1We hereby aucthorizc Pine View Crematory t1.Cn:�fuv rum,l t4 Cremate the remains of the deceased. Iin,rf(oPTardAL,;, _Ifwe hereby authorize the named funeral director to provide for delivery to and cremation by an alternate crematoryr,if deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and address of such alternate crematory. FINAL D4SPQ4mQN The person authorized to receive the cremated remains of the deceased from the crematory is Name:ILlillor Funeral Homo Address:6367 N`1S Rte.30, Indian Lake, NY 12842 Phone.618-648-0011 The cremated remains of deae3Sed will be disposed of as follows. return to family tt for any reason the person named above does riot take possession of the cruniated remans, Pine View Crematory is authorized to give pcaaess►on of the remains to_ t]y delfvery IY ine.3 f1k7C 1r1IM1 in pa$ori or by registered rriaii_ Cheryl A Brock DoS-1696-r(Rev.04,120) Page 2 of 3